Should you have any queries, or need help completing this form, please don t hesitate to contact us.

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1 City & Hackney Carers Centre, Prideaux House, 10 Church Crescent, E9 7DL Tel: Fax: Carers Registration & Hackney Carers Card Application Form Dear Carer, This is the Initial Registration Form from the Carers are the Bedrock support service. It must be completed in order to access our services and to receive a Hackney Carer s Card. What you can expect from us: The Carers Co-ordination Service (CCS) is where you tell us about your needs and which services you think you need to access to support you in your caring role. We will also ask you to complete your Individual Development Plan (IDP). This will act as your guide to enable you to understand which support services are available. The aim is to improve your quality of life as a carer. Please complete this form and return to: City & Hackney Carers Centre, Prideaux House, 10 Church Crescent, E9 7DL Should you have any queries, or need help completing this form, please don t hesitate to contact us. Tel: Fax: CCSAdmin@hackneycarers.org.uk Carers are the Bedrock. Funded by 1

2 HACKEY CARERS CARD SECTIO To apply for a Hackney Carers Card, please complete the rest of the form and ask a health/social care professional who has knowledge of your care to complete the verification section. Who can apply: Carers, aged 18 or over, who provide care for a Hackney resident of any age can apply for a Hackney Carers Card. A carer is someone who provides regular, unpaid help to a relative or friend who is frail, disabled or suffers from an illness. Before you return the form please: Ask a health/social care professional, for example, a district nurse, community psychiatric nurse, social worker, care manager, your GP, occupational therapist or voluntary organisation, to complete the PROFESSIOAL VERIFICATIO section. ECLOSE TWO PASSPORT SIZE PHOTOGRAPHS OF YOURSELF (not the cared for person). Sign the CARER section and if they are able to, please ask the person you care for to sign the CARED FOR section. Please note that registration is renewable every three years. We will write to you a month before your card expires. Please note that the Carers Card may only be used by you, the carer/cardholder. What happens next: The card is free to carers. Cardholders can take advantage of benefits including discounts at many local retailers and can enjoy concessionary rates at all Hackney Leisure Centres. When your application has been processed and approved, we will send you a card and a shop guide which provides details of the participating retailers and contact details for Hackney Leisure Centres. If you have any queries regarding the application form please call City & Hackney Carers Centre on Your Hackney Carers Card application will be processed and you will automatically go onto Hackney s Carers Register, a free mailing list, to receive quarterly information updates on services for carers. Please tick if you do not wish to go on the Carers Register to receive information. We welcome any feedback or ideas regarding the scheme. Kind regards Carers are the Bedrock 2

3 CARER S DETAILS Mr / Mrs / Ms / Other (please specify) First names: Address: Post code: Mobile: Area/Estate: Telephone number: Date of birth: Gender: Male Female Trans Intersex First spoken language: Do you need an interpreter? Yes o If yes, in what language? Ethnicity: Religion: Sexual Orientation: Bisexual Gay Heterosexual Lesbian Prefer not to say Details of any disability, illness or condition: GP surgery ame: Telephone o: GP Address: Have you told your GP that you are caring for someone? Yes o What is your relationship to the person you care for: Partner Parent Son Daughter Sibling eighbour Friend Grandchild Other Hours caring per week: Are you the main carer: Yes / o How long have you cared for this person? Who else provides care? What kind of care do you provide? Help with personal care (washing etc.) / Domestic help (cleaning etc) / Emotional care Prompting medication / Help with bills/finance / Other (please explain below) Have you been issued a Hackney Carers Card? Yes o If you don t yet have a Hackney Carers Card, but would like to apply for one, please complete the Carers Card section (pages 4-5) 3

4 CARED FOR PERSO S DETAILS: Mr / Mrs / Ms / Other (please specify) First names: Address: Post code: Mobile: Area/Estate: Telephone number: Date of birth: Gender: Male Female Trans Intersex First spoken language: Do you need an interpreter? Yes / o If yes, in what language? Ethnicity: Religion: Sexual Orientation: Bisexual Gay Heterosexual Lesbian Prefer not to say Details of any disability, illness or condition: GP surgery ame: Telephone o: GP Address: Have you received a Carers are the Bedrock Information Pack? Yes If no, would you like us to send you one? Yes o o Please tell us which carers services you would like to access: Where did you hear about us? Declaration: Your details will be added to the Hackney Carers Register and you will receive regular information from us informing you of upcoming events and relevant information. You can then, through the Individual Development Plan (IDP) tell us what your primary needs are and then decide which partner organisation you wish to be referred to for your Carers eeds Assessment. The Carers Register is a confidential database which we administer on behalf of the London Borough of Hackney and your information will not be shared with anyone outside of the London Borough of Hackney or the Carers Are the Bedrock partnership without your consent. I agree that the above information is correct. I have been informed of the services that may be relevant to my needs and it is my decision to access the services that I have chosen. Signed (carer) Referrer s details - First name: Organisation ame: Date: Tel umber: 4

5 Professional Verification: Verification can be made by, for example, a district nurse, community psychiatric nurse, social worker, care manager, your GP, occupational therapist or voluntary organisation. In what capacity do you know this carer? How long have you known this carer? Are you familiar personally with their caring role? Do you confirm that the carer provides regular and substantial care and these details are true to the best of your knowledge? Any other comments you would like to make to support this application? First name: Organisation ame: Contact umber: For professional verification please attach proof of identity i.e. a business card or a stamp mark. STAMP 5

6 OFFICE USE OLY Has the carer received an information pack? Y Inputted carer on the database? Y Has the carer been sent a Hackney Carers Card team? Y Referred for Individual Developmental Plan? Y Registration and Carers Card application scanned and uploaded onto the database? Y Referred to other services? Y If Yes which services? 6